Medicare Drug Pricing Negotiations: Assessing Constitutional Structural Limits

A series of structural constitutional arguments lodged in multiple cases against Centers for Medicare and Medicaid Services' (CMS) authorities to negotiate prescription drug prices via the 2022 Inflation Reduction Act threaten the legitimacy of CMS program and federal agency powers.

INTRODUCTION: Introducing a Special Symposium

This special JLME symposium addresses ways that federal policy can incentivize innovation in medical therapeutics and make pharmaceuticals more financially accessible.

Pharmacy Benefit Managers in the Eye of the Storm: Growing Multipartite Scrutiny

The high cost of prescription drugs in the U.S. remains an ongoing national challenge. A recurring focal point in discussions over this distressing steady state is the role(s) played by Pharmacy Benefit Managers (PBMs) who negotiate drug prices with pharmaceutical manufacturers, conduct drug utilization reviews, engage in disease management, and see to formulary creation. At their inception, the multiple newly established PBMs were arguably intent on constraining the rise of prescription drug prices. At the time of this writing, however, the lion share of a far less competitive PBM market is controlled by CVS Caremark, Express Scripts, and OptumRx. It is this evolving reality which could be interpreted to mean that the PBMs may have become part of the problem, rather than part of the solution. Expanded scrutiny of the PBMs by Federal and State authorities as well as by Professional Medical Associations must not be delayed with an eye toward affording the public with relief from the high cost of prescription drugs.

Prescription Drugs and Mitochondrial Metabolism

Mitochondria are central to the physiology and survival of nearly all eukaryotic cells and house diverse metabolic processes including oxidative phosphorylation, reactive oxygen species buffering, metabolite synthesis/exchange, and Ca2+ sequestration. Mitochondria are phenotypically heterogeneous and this variation is essential to the complexity of physiological function among cells, tissues, and organ systems. As a consequence of mitochondrial integration with so many physiological processes, small molecules that modulate mitochondrial metabolism induce complex systemic effects. In the case of many common prescribed drugs, these interactions may contribute to drug therapeutic mechanisms, induce adverse drug reactions, or both. The purpose of this article is to review historical and recent advances in the understanding of the effects of prescription drugs on mitochondrial metabolism. Specific 'modes' of xenobiotic-mitochondria interactions are discussed to provide a set of qualitative models that aid in conceptualizing how the mitochondrial energy transduction system may be affected. Findings of recent in vitro high-throughput screening studies are reviewed, and a few candidate drug classes are chosen for additional brief discussion (i.e. antihyperglycemics, antidepressants, antibiotics, and antihyperlipidemics). Finally, recent improvements in pharmacokinetic models that aid in quantifying systemic effects of drug-mitochondria interactions are briefly considered.

Characteristics of Prescription Drug Use Among Individuals With Multiple Sclerosis in the US Medicare Population

BACKGROUND

Few studies have characterized the full spectrum of prescription drug use for individuals with multiple sclerosis (MS). The objective of this study was to describe patterns and expenditures for disease-modifying therapies (DMTs) and other prescription drugs among Medicare beneficiaries with MS.

METHODS

Using Medicare claims data in 2014, we identified a cohort of Medicare beneficiaries with 12 months of continuous eligibility and 3 or more MS-related inpatient, outpatient, or prescription claims. We quantified the number, type, and costs of prescribed DMTs and other medications for MS-related symptoms. Medication costs were calculated according to whether beneficiaries received additional subsidies, which eliminate most out-of-pocket costs.

RESULTS

Of 43,283 Medicare beneficiaries identified with MS, 70% were DMT users. Most used self-administered DMTs (67%), and 3% used natalizumab; 93% received a supportive care medication. Among the 82% of individuals without subsidies, the annual median total and out-of-pocket DMT costs were $56,794 (interquartile range [IQR], $44,837-$62,038) and $4566 (IQR, $849-$5270), respectively. The most commonly used supportive care drugs were antidepressants (62%), opioid analgesics (50%), antispasticity drugs (47%), and anticonvulsants (46%). Annual median total and out-of-pocket costs for these drugs were $15,134 (IQR, $6571-$19,620) and $255 (IQR, $56-$877), respectively.

CONCLUSIONS

Most Medicare beneficiaries with MS using DMTs face considerable out-of-pocket costs. Beneficiaries also used a significant number of medications potentially used for MS-related symptoms, although total and out-of-pocket costs were modest.

Impact on In- and Outpatient Hospital Drug Prescriptions of Including a More Expensive Me-Too Antidepressant in a Hospital Drug Formulary: a Controlled Longitudinal Study

BACKGROUND

The effect of the inclusion of a more expensive me-too medicine in a hospital drug formulary (HDF) on both in- and out-of-hospital utilization, and the contextual factors which influence this type of induction is rarely studied. Accordingly, this work aimed to quantify the effect of the decision of a hospital of including a more expensive me-too antidepressant in its HDF.

METHODS

A controlled longitudinal study was carried out in a Regional Health Service of Spain. We performed a segmented regression analysis with control group. We used the following dependent variables: defined daily doses (DDD) per 1000 inhabitants per day, DDD per 100 bed days, and cost per DDD.

RESULTS

At a hospital level, the modification in the formulary led to utilization changes: (1) an increase in immediate consumption of the newly included me-too drug; and, (2) an annual 25.96% [95%CI: 2.96%-48.95%] decrease in the adjusted trend of the already existing parent antidepressant. The adjusted trend of the cost per DDD of the sum of all medications in the therapeutic group increased by 20.03% annually [95%CI:3.24%-36.82%]. In the out-of-hospital setting utilization changes were: (1) the adjusted trend of the newly included me-too drug rose by 12.14% annually [95%CI:4.97%-19.30%]; and, (2) that of the parent drug underwent a negative change in trend of 4.18% annually [95%CI: 0.00%-8.36%].

CONCLUSIONS

The inclusion of a more expensive me-too drug in the HDF led to increased consumption of this more expensive me-too drug both in- and out-of-hospital. This article is protected by copyright. All rights reserved.

Impact of Covid-19 containment on community pharmaceutical spending in Andalusia - Spain

Background:

In the field of health, the year 2020 will be remembered for testing (stressing) all health institutions and their forms of management (centralised and decentralised). The everyday activity of primary and hospital care was significantly altered by the introduction of telephone consultations, which reduce the number of visits to health centres or hospitals and are still relevant today in the face of successive waves of the pandemic.

Objective:

To analyse whether population confinement due to the COVID-19 pandemic had an impact on the dispensing of medications in community pharmacies and the associated spending during the period March-July 2020 in Andalusia (Spain).

Methods:

A time series analysis applying econometric model analysis techniques to confirm or rule out whether the lockdown caused by the COVID-19 pandemic had an impact on the dispensing of medications by community pharmacies and the associated expenditures. The variables used were the number of medication containers dispensed by community pharmacies (charged to the public funds of the Spanish National Health System) and the expenditure on prescription drugs, both in relation to the population. The analysis was performed within the region of Andalusia, which has 8,464,441 inhabitants.

Results:

The data obtained from the time series confirmed that there were no significant differences during the studied period between the number of medication containers actually dispensed and the number that would have been expected to be dispensed according to the trend in this variable for the sample period. The expenditure results followed the same pattern.

Conclusions:

The health crisis produced by the COVID-19 lockdown had no impact on medication consumption in Andalusia.

Assessment of drug-prescribing perception and practice among dental care providers: a cross-sectional Lebanese study

Background:

Dentists play an essential role in providing high-quality dental care, taking into consideration the clinical context and concomitant medications taken by the patients.

Objective:

This study aimed to assess drug-prescribing perception and practices in addition to drug-related educational needs among Lebanese dentists; it also evaluated the need for interprofessional collaboration between dentists and pharmacists.

Methods:

An exploratory cross-sectional study using an online questionnaire targeted a sample of dentists from all Lebanese districts. Participants gave their consent by accepting to complete the survey (ethics approval reference: USJ-2016-63). The questionnaire consisted of closed-ended questions exploring: 1) drug-prescribing perception, 2) drug-prescribing practice, and 3) collaboration with pharmacists regarding their respective roles in providing appropriate counseling to patients. Two indexes were created: the first evaluated self-confidence in prescribing medications, and the second assessed dentists’ confidence in pharmacists. Logistic regressions were performed, taking each index as a dependent variable.

Results

A total of 137 dentists completed the survey (59% females; mean age: 42.17; SD: 13.78 years). The majority had a fair to good perceived knowledge in pharmacology and therapeutics (80.3%), only 30.7% reported to be sufficiently equipped to prescribe safely. Dentists exhibited particularly low perceived knowledge about prescribing in elderly patients, dosing, medication use in pregnancy, drug interactions, and adverse reactions. Dentists specialized in periodontics had the lowest odds of having self-confidence in prescribing drugs (aOR=0.25; p<0.001). Also, 64.3% declared that they routinely check a reference source before prescribing, and 78% relied on pharmaceutical companies and medical representatives to get information on medications. While 61% declared that pharmacists should provide oral care counseling, only half of them encouraged their patients to talk to their pharmacists about their medications. Only 15% considered that patients are getting enough counseling from the pharmacist, with a global confidence index below the median value, suggesting the need for more collaboration, especially with periodontists who exhibited the lowest confidence in pharmacists (aOR=0.45).

Conclusions

Lebanese dentists reported some lack of knowledge and confidence in prescribing practices. Education, training, and close collaboration between pharmacists and dentists are essential to overcome these problems and avoid potential harm to patients.

Subsidy Design in Privately Provided Social Insurance: Lessons from Medicare Part D

The efficiency of publicly-subsidized, privately-provisioned social insurance programs depends on the interaction between strategic insurers and the subsidy mechanism. We study this interaction in the context of Medicare's prescription drug coverage program. We find that the observed mechanism is successful in keeping "raise-the-subsidy" incentives relatively low, acts much like a flat voucher, and obtains a level of welfare close to the optimal voucher. Across a range of counterfactuals, we find that more efficient subsidy mechanisms share three features: they retain the marginal elasticity of demand, limit the exercise of market power, and preserve the link between prices and marginal costs.

Direct-to-Consumer Prescription Drug Advertising and Patient-Provider Interactions

BACKGROUND

Direct-to-consumer prescription drug advertising is prevalent and affects patient care. Previous research that examined its effect on the patient-provider relationship predates many changes in the advertising and medical landscape that have occurred in the last decade, such as the rise in online promotion and the push for value-based medicine.

METHODS

We conducted a nationally representative mail-push-to-web survey of 1744 US adults in 2017 to explore how patients view the effects of direct-to-consumer prescription drug advertising on patient-provider interactions.

RESULTS

Most respondents (76%) said they were likely to ask a health care provider about advertised drugs; 26% said they had already done so. Among the 26% of respondents who talked to a health care provider about a specific prescription drug they saw advertised, 16% said they received a prescription for the advertised drug. Few respondents (5%) reported that advertising had caused conflict with a health care provider, 16% said it had caused them to question their provider's advice, and 23% said they were likely to look for a different provider if their provider refused to prescribe a requested brand name drug.

DISCUSSION

These results suggest that direct-to-consumer advertising is driving some patients to discuss specific products with their health care providers but that most patients do not believe advertising has a negative influence on the patient-provider interaction itself.

A nationwide web-based survey of a sample of Italian community pharmacists' perceptions and opinions about online sales of medicines and falsified drugs

Background

Throughout Europe, legal online pharmacies increasingly sell online drugs as well as other products such as dietary supplements. Online sale of pharmaceuticals however is closely connected to the phenomenon of drug falsification.

Objective

The aim of this study was to assess the opinions of a sample of Italian community pharmacists towards the sale of pharmaceuticals on the web, as well as their knowledge and experience with falsified drugs.

Methods

A self-administered questionnaire was distributed by means of an online platform between October 2016 and January 2017. Collected information included: demographics, workplace and role, opinions towards the online sale of pharmaceuticals, whether the pharmacy has a website, knowledge and opinions about falsified drugs.

Results

A total of 668 community pharmacists completed the questionnaire (mean age: 48.5, SD 12.4 years, 52.3% women). Favourable opinions about online sale of pharmaceuticals were expressed by 4.9% of participants for prescription drugs, 25.4% for nonprescription drugs, and 51.6% for other products. Favourable opinions occurred more often among males and owners/directors of pharmacies in comparison to females and employees, and among pharmacists working in pharmacies with websites doing e-commerce. Knowledge about falsified drugs was limited, with 24.5% of respondents failing to indicate that falsified drugs may contain less or different ingredients, 46.4% less and/or different excipients, and 72.3% ignoring that falsified drugs may be lethal. One in 3 respondents didn't know about falsified drugs in Italy, however 51 participants had previous experience with falsified drugs and 21 provided specific information.

Conclusions

Italian community pharmacists have low confidence in the online sale of pharmaceuticals, as well as alarmingly limited knowledge about falsified drugs, even if many of them reported previous experiences. Results may support targeted interventions to increase pharmacists' knowledge about pharmaceuticals and the web, as well as concerning falsified drugs, and suggest community pharmacies as key components of integrated systems aimed at monitoring falsified drugs.

Impact of direct-to-consumer drug advertising during the Super Bowl on drug utilization

BACKGROUND

Direct-to-consumer advertising (DTCA) of prescription drugs impacts patients' requests for medications, and clinician prescribing. However, the impact of DTCA during the Super Bowl has not been previously described.

OBJECTIVE

Evaluate the impact of prescription drug DTCA during the Super Bowl on drug utilization using 2014-2016 Medicare data.

METHODS

Efinaconazole was advertised during Super Bowls XLIX (02/01/2015) and L (02/07/2016). The number of prescriptions for efinaconazole and for a comparator drug, tavaborole, were calculated in 31-day intervals from July 2014-December 2016. Interrupted time-series analysis models were created to test changes in trends of prescriptions for efinaconazole and tavaborole.

RESULTS

Following Super Bowl XLIX, the number of prescriptions per 100,000 Medicare beneficiaries increased by 91% for efinaconazole, and 275% for tavaborole. After Super Bowl L, the number of prescriptions increased significantly for efinaconazole (p-value<0.001), but not for tavaborole (p = 0.70). Interrupted time-series analyses estimated that, in the absence of DTCA during Super Bowl XLIX, prescriptions for efinaconazole would have increased by 40%, instead of the observed 91%. For tavaborole, prescriptions would have increased by 90% instead of 275%.

CONCLUSIONS

DTCA during the Super Bowl resulted in sharp increases in utilization of the prescription drug advertised, which supports further regulation of DTCA.

Development of a Method for Extracting Structured Dose Information from Free-Text Electronic Prescriptions

In this study, we sought to develop an automatic parser tool for unstructured free-text electronic prescriptions, focusing specifically on defining the daily dose. We manually coded a set of electronic discharge prescriptions and established the most reliable rules to structure the medication data. A named-entity recognition (NER) parser tool was implemented, which was capable of identifying 90% of the doses and 86% of the frequencies from 255 dosage instructions.

[Perception and Attitudes About Rational Prescription During Medical Training: Results of Focus Groups Including Medical Students and Residents]

INTRODUCTION

Clinical pharmacology educational strategies for medicine students seek to foster skills that range from technical knowledge to the development of behaviors that ensure rational prescribing decisions. The authors present the results of a study to evaluate the perceptions, attitudes and behaviors linked with rational prescribing throughout training.

MATERIAL AND METHODS

Four focus groups were held with first, third and fifth year medical students and residents from the first years of various specialties, with a total of 29 participants. A semi-structured questionnaire with open-ended questions was used to facilitate interaction between the participants, alongside case-studies to explore the behaviors associated with therapeutic decisions.

RESULTS

The analysis of the references showcased an evolution of concepts throughout academic training. References regarding guidelines and effectiveness emerge during the third year; safety and treatment personalization emerge during the fifth year and specialist training. Efficacy studies, systematic reviews, regulatory documents and online platforms were considered the most relevant sources of information.

DISCUSSION

The literature review showcases the need to implement strategies dedicated to the development of adequate skills for rational prescribing. The use of focus groups may be a useful methodology to engage students in self-evaluation of their skills and inform faculty of the perceptions and behaviors of students.

CONCLUSION

This analysis illustrates the awareness of students and young physicians to the need to adapt therapeutic approaches to the characteristics of the patient. These concepts should be reinforced so that young doctors feel more prepared for rational prescription in complex clinical situations.

Trends in high intensity statin use among secondary prevention patients 76 years and older

Background:

High intensity statin therapy (HIST) is the gold standard therapy for decreasing the risk of recurrent atherosclerotic cardiovascular disease (ASCVD); however, little is known about the use of HIST in older adults with ASCVD.

Objectives:

The aim of this cross-sequential study was to determine trends in statin intensity in older adults over a 10-year timeframe.

Methods:

The study was conducted in an integrated healthcare delivery system. Patients were 76 years or older with validated coronary ASCVD. Data were collected from administrative databases. Statin intensity level was assessed in eligible patients on January 1st and July 1st from January 1, 2007 to December 31, 2016.

Results:

Overall, a total of 5,453 patients were included with 2,119 (38.9%) and 3,334 (61.1%) categorized as HIST and Non-HIST, respectively. Included patients had a mean age of 79.8 years and were primarily male and white and had a cardiac intervention. The rate of HIST use increased from 14.5% to 41.3% over the study period (p<0.001 for trend). Conversely, the rates of moderate and low intensity statin use decreased from 61.8% and 9.8% to 41.2% and 4.8%, respectively (both p<0.001 for trend). Similar trends were identified for females and males.

Conclusions:

The percentage of patients with ASCVD 76 years and older who received HIST substantially increased from 2007 to 2016. This trend was identified in both females and males. Future comparative effectiveness research should be conducted in this patient population to examine cardiac-related outcomes with HIST and Non-HIST use.

Investigating the efficacy of an interactive warning for use in labeling strategies used by us pharmacies

Background

United States pharmacies repackage medications into multi-dose vials, enabling customized dosing for prescription drugs. Investment in infrastructure has made this the predominant approach to packaging for US prescriptions. Although recent changes to labeling now discourage the use of auxiliary labels (small stickers highlighting information germane to the safe and effective use), they are still allowed by USP<17>, provided their use comes from an evidence-based perspective.

Objectives

Evaluate how 'interactive,' placements of auxiliary labels (placement requiring physical manipulation of the warning to accomplish a task (e.g. opening)) garner attention as compared to those placed vertically or horizontally.

Methods

Ninety-six participants were eye tracked while opening three prescription vials (each with an auxiliary warning label with a different placement: vertical, horizontal and interactive). Recall and recognition were tested subsequently. Linear mixed models were used to analyze the continuous variables while the binary response variables were analyzed using generalized linear mixed models. The effect of auxiliary labels was fitted as a fixed effect and the subject-to-subject variation was considered as a random effect in the model. Participants' age, health literacy and sex were added to the models if their effect was statistically significant at alpha=0.05.

Results

The placement of the warnings significantly impacted the time spent viewing the information they contained at alpha=0.05; people spent significantly longer on interactive placements (0.96; SD 0.13 seconds) than either, horizontal placements (0.27; SD 0.037 seconds) or those placed vertically (0.18 seconds; SD 0.035). Participants were equally as likely to see information presented in an interactive placement (90%; SD 3.8) or horizontal placement (78%; SD 05.5) but less likely to view warnings placed vertically (60%; SD 6.9). Free recall responses also supported the use of interactive placement (62%; SD 6.8 recall) as compared to horizontal placements which were 29%; SD 3.0 and 20%; SD 6.0 for vertical placements.

Conclusions

Data provides evidence which suggests that interactive and horizontal placements out-perform auxiliary labels placed vertically on prescription vials with regard to garnering patient attention.

Secular Trends in the Cost of Immunosuppressants after Solid Organ Transplantation in the United States

BACKGROUND AND OBJECTIVES

Immunosuppressive medications are critical for maintenance of graft function in transplant recipients but can represent a substantial financial burden to patients and their insurance carriers.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

To determine whether availability of generic immunosuppressive medications starting in 2009 may have alleviated some of that burden, we used Medicare Part D prescription drug events between 2008 and 2013 to estimate the average annualized per-patient payments made by patients and Medicare in a large national sample of kidney, liver, and heart transplant recipients. Repeated measures linear regression was used to determine changes in payments over the study period.

RESULTS

Medicare Part D payments for two commonly used immunosuppressive medications, tacrolimus and mycophenolic acid (including mycophenolate mofetil and mycophenolate sodium), decreased overall by 48%-67% across organs and drugs from 2008 to 2013, reflecting decreasing payments for brand and generic tacrolimus (21%-54%), and generic mycophenolate (72%-74%). Low-income subsidy payments, which are additional payments made under Medicare Part D, also decreased during the study period. Out-of-pocket payments by patients who did not receive the low-income subsidy decreased by more than those who did receive the low-income subsidy (63%-79% versus 24%-44%).

CONCLUSIONS

The decline in payments by Medicare Part D and by transplant recipients for tacrolimus and mycophenolate between 2008 and 2013 suggests that the introduction of generic immunosuppressants during this period has resulted in substantial cost savings to Medicare and to patients, largely reflecting the transition from brand to generic products.

The Effect of Prescription Drug Coverage on Mortality: Evidence from Medicaid Implementation

This paper estimates the effect of Medicaid prescription drug spending on mortality. I use the group- and state-specific roll out of Medicaid drug coverage to isolate plausibly exogenous variation in drug expenditures. I find that a $1 increase in Medicaid drug expenditures per resident reduces mortality from internal causes by 2.0 deaths per hundred thousand, a decline of 0.23%. I find relatively large effects for: (1) medically-treated diseases which pose an immediate risk of death, (2) impoverished areas which received a disproportionate share of state Medicaid dollars, and (3) areas with a high ratio of medical to surgical physicians.

Source of medicines and medicine information by self-reported persons living with hypertension and diabetes in rural and urban Ghana

Objectives:

This study was conducted to determine the source of medicines and medicine information of persons living with hypertension and diabetes in rural and urban Ghana and assessing if they are influenced by predisposing and enabling factors as defined by Andersen’s behavioural model.

Methods:

A population based cross sectional study was conducted in four (4) rural and four (4) urban districts in the Ashanti Region of Ghana. A multistage and proportional sampling method was used in enrolling participants aged 18 years and above. A pre-tested structured questionnaire was used to collect primary data from respondents. Data collected was exported to STATA for analysis. Descriptive analysis was performed. Chi-square tests/Fisher’s exact test and multinomial logistic regression models were used to establish association between variables.

Results:

A total of 336 self -reported persons with hypertension and diabetes were enrolled in the study with 199(59.23%) living in urban communities. The majority of participants with hypertension and diabetes living in the rural communities 77 (56.20%) were females contrasting with the male majority in urban communities 106 (53. 27%). In the rural communities, 49 (35.77%) of participants sourced medicines from the health centre while 45 (32.85%) and 35(25.55%) sourced medicines from the hospital and over the counter medicine shop (OTCMS) respectively. In the urban communities, 153 (76.88%) sourced medicines from the hospital while 33 (16.58%) sourced medicines from the pharmacy. The predisposing factor age (OR: 1.1, 95%CI 1.040-1.210) under OTCMS, age (OR 1.0, 95% CI: 1.002-1.066) under hospital and enabling factor socioeconomic status (OR: 0.3, 95%CI 0.085-0.855) under Hospital influenced participant’s source of medicine in the urban communities. The results also revealed that majority of participants in both rural 99 (72.26%), and urban 164 (82.41%) communities sourced medicine information mainly from public healthcare facilities, pre-disposing factors; age (OR 1.1 95%CI 1.032-1.270) under family member, age (OR 1.1, 95%CI 1.022-1.167) under friend health professional, age (OR 1.1, 95%CI 1.050-1.147) under nearest health institution, marital status (OR: 0.004, 95%CI 0.003-0.441) under friend health Professional were found to influence participants’ source of medicine information in the urban communities while in the rural communities the predisposing factor marital status (OR 10.6, 95%CI 1.044 -106.835), education (OR: 26.1, 95%CI 1.271-537.279) under friend health professional, age (OR 1.1, 95%CI 1.002-1.187), educational level (OR 30.6, 95%CI 1.718-546.668) under nearest health institution and enabling factor socio-economic status (OR 6.6, 95%CI 1.016 -43.510) under nearest health institution influenced one’s source of medicine information.

Conclusions:

Majority of inhabitants with hypertension and diabetes in both rural and urban communities, sourced medicines and medicine information from public health institutions though a larger proportion was recorded in the urban communities. More participants in the rural communities than in the urban communities sourced medicines and medicine information from community pharmacies. Participants’ source of medicine and medicine information was influenced by both predisposing and enabling factors.

Development and validation of a survey instrument to measure factors that influence pharmacist adoption of prescribing in Alberta, Canada

Objective

Study objectives were to develop a questionnaire to assess factors influencing pharmacists' adoption of prescribing (i.e., continuing, adapting or initiating therapy), describe use of pre-incentive and mixed mode survey, and establish survey psychometric properties.

Methods

Questions were developed based on prior qualitative research and Diffusion of Innovation theory. Expert review, cognitive testing, survey pilot, and main survey were used to test the questionnaire. Six content experts reviewed the questionnaire to establish face and content validity. Ten pharmacists from diverse practice settings were purposefully recruited for a cognitive interview to verify question readability. Content analysis was used to analyze the results. A pre-survey introduction letter with a monetary incentive was mailed via post to 100 (i.e. pilot) and 700 (i.e., main survey) randomly selected pharmacists. This was followed by an e-mail with a personalized link to the online questionnaire, e-mail reminders, and a telephone reminder if required. The psychometric properties of scales were evaluated with an exploratory factor analysis and Cronbach's alpha. Scale responses were described.

Results

Engagement of six experts and ten pharmacists clarified definitions (e.g., prescribing), terminology, recall periods, and response options for the 34-item response scale. Fifty-six pharmacists completed the online pilot survey. Based on this data, ambiguous questions and routing issues were addressed. Three hundred and seventy-eight pharmacists completed the online main survey for a response rate of 54.6%. The factors analysis resulted in 27 questions in eight scales: (1) self-efficacy, (2) support from practice environment, (3) support from interprofessional relationship, (4) impact on professionalism, (5) impact on patient care), (6) prescribing beliefs, (7) technical use of electronic health record (EHR) and (8) patient care use of the EHR. Prescribing beliefs and technical use of the EHR scales had low reliability while the remaining six scales had strong evidence for reliability and validity.

Conclusion

Through a multi-stage process, a survey instrument was developed to capture pharmacists' perceptions of prescribing influences. This questionnaire may support future research to develop interventions to enhance adoption of prescribing and enhance direct patient care by pharmacists.

Using Drug Prescribing Patterns to Identify Stewards of Cost-Conscious Care

PURPOSE

To characterize family physicians (FPs) who are stewards of care by consistently prescribing omeprazole over esomeprazole.

METHODS

Cross-sectional analysis of physicians prescribing omeprazole or esomeprazole under Medicare Part D in 2014.

RESULTS

There was a regional trend with 49% of Western FPs but only 6% of Southern FPs rarely prescribing esomeprazole. Physicians had increased odds of being a steward if they worked with a care coordinator (P < .001), at a patient-centered medical home (P < .001), or in a large practice (P < .001).

CONCLUSIONS

If these findings are replicated across multiple drugs, future outreach could be conducted based on provider prescribing patterns.

Opioid Prescription Drug Use and Expenditures in US Outpatient Physician Offices: Evidence from Two Nationally Representative Surveys

BACKGROUND

Opioids are widely prescribed for their analgesic properties. Chronic opioid use is a persistent problem in the US. Nevertheless, little is known about its prescribing and utilization patterns and overall expenditures.

OBJECTIVE

This study examined secular trends in opioid prescription drug utilization and expenditures, along with factors associated with opioid prescription drug use in US physician offices.

METHODS

National Ambulatory Medical Care Survey (NAMCS) and Medical Expenditure Panel Survey (MEPS) data (2006-2010), both nationally representative surveys, were used to assess the trend, predictors of opioid prescription among US adults (more than 18 years) and the opioid-associated expenditures as a whole and borne by the patients in outpatient settings.

RESULTS

Opioid prescription drugs use among US adults in outpatient settings, as a percentage of all prescription drugs, showed a gradual increase since 2006, leveling off in 2010. Opioid prescription drug expenditures showed an upward trend from 2009 after declining over three years. Mean out-of-pocket payments per prescription steadily declined over study period.

LIMITATIONS

Cross-sectional nature and visit based information of NAMCS do not provide the actual prevalence and the reason for opioid prescription.

CONCLUSIONS

Given the upward trend in opioid prescription drug utilization and associated expenditures, clinicians may benefit from evidence-based methods of monitoring prescription opioid use to prevent misuse, abuse, and other adverse patient outcomes.

FUNDING

Drs. Qureshi, Haider, Ball, Horner and Bennett's efforts are partially supported by the University of South Carolina's ASPIRE I. Dr. Wooten's effort is funded by the National Institute on Drug Abuse (K01DA037412).

Assessment of the rates and characteristics of the short-term supply of medication (Tider) from an integrated healthcare delivery system in the United States

Objectives:

The purpose of this study was to describe the rate of medication short-term supply dispensings (tider), patient and medication characteristics associated with a tider, and costs for tider dispensings in an integrated healthcare delivery system in Colorado, United States.

Methods:

This was a retrospective study conducted in an integrated healthcare delivery system’s outpatient clinics. All patients who had a prescription dispensed for a study medication at any of the system’s 28 outpatient pharmacies during the first quarter of 2016 were included. A tider was identified as a 3-day supply of a prescription medication that was dispensed at no charge to a patient. The quarterly tider rate and the per member per month (PMPM) cost of tiders were estimated. Patient and medication characteristics associated with a tider were assessed.

Results:

A total of 444,225 study medications were dispensed for 135,907 patients during the study period. There were 3,430 (0.77%, 95%CI 0.75%:0.80%) medications dispensed as a tider. The PMPM cost of tider medications and their dispensing fees was USD 0.03. There were 1,092 (0.8%) and 134,815 (99.2%) patients who did and did not, respectively, have at least one tider dispensed during the study period. Patient characteristics strongly associated with having had a tider dispensed included being older, male, and a Medicare beneficiary. Cardiovascular and neuromuscular medications had the highest rates of tider dispensing.

Conclusions:

The rate of tider dispensing was relatively low; however, approximately one out of 125 patients had at least one tider. Patients who had a tider were more likely to be older, female, a Medicare beneficiary, and having had a previous tider dispensing and a higher burden of chronic disease. The tider medication was more likely to be a cardiovascular or neuromuscular medication class and more likely to be dispensed on a weekend. The total cost of dispensing a tider appears reasonable since the benefits of providing patients with needed medications likely outweigh the cost. Future studies should be performed to assess the impact of tider dispensing on health outcomes.

Comparing Adoption of Breakthrough and "Me-too" Drugs among Medicare Beneficiaries: A Case Study of Dipeptidyl Peptidase-4 Inhibitors

PURPOSE

"Me-too" drugs are new pharmaceuticals with the mechanism of action of an existing drug and are considered less innovative than breakthrough drugs. The objective of this study was to evaluate whether the adoption patterns of the breakthrough drug sitagliptin and the "me-too" drug saxagliptin differed; and to assess whether the patterns differed between Medicare stand-alone (PDP) and Medicare-Advantage Part D (MA-PD) plans.

METHODS

Pharmacy claims from a 5% random sample of Medicare Part D beneficiaries were used to identify all prescriptions filled for sitagliptin (breakthrough drug) and saxagliptin ("me-too" drug) between October 1, 2006 and December 31, 2011. The number of new sitagliptin and saxagliptin users by month and type of plan were plotted, and Bass diffusion models were constructed to estimate the rate of diffusion.

RESULTS

Sitagliptin had a longer adoption life than saxagliptin, and its adoption was quicker among MA-PD than PDP beneficiaries: it peaked at 51 and 66.7 months after its approval, respectively. However, the adoption of saxagliptin did not differ by type of plan: it peaked at 20.5 months in PDP and 22.9 months in MA-PD. At the end of our study, the market share of the innovative drug sitagliptin measured as the cumulative number of users since market entry was almost nine times higher than the "me-too" drug, saxagliptin.

CONCLUSIONS

The breakthrough drug sitagliptin had a much longer adoption life compared to the "me-too" drug saxagliptin, and the breakthrough drug sitagliptin was adopted quicker among managed care plans compared to PDP plans.

Measuring medication adherence in patients with incident hypertension: a retrospective cohort study

Background

Though pharmacy claims data are commonly used to study medication adherence, there remains no standard operational definition for adherence especially for patients on multiple medications. Even when studies use the same terminology, the actual methods of calculating adherence can differ drastically. It is unclear whether the use of different definitions results in different conclusions regarding adherence and associated outcomes. The objective of our study was to compare adherence rates and associations with mortality using different operational definitions of adherence, and using various methods of handling concurrent medication use.

Methods

We conducted a cohort study of patients aged ≥65 years from Manitoba, Canada, with incident hypertension diagnosed in 2004 and followed to 2009. We calculated adherence rates to anti-hypertensive medications using different operational definitions of medication adherence (including interval and prescription based medication possession ratios [MPR] and proportion of days covered [PDC]). For those on concurrent medications, we calculated adherence rates using the different methods of handling concurrent medication use, for each definition. We used logistic regression to determine the association between adherence and mortality for each operational definition.

Results

Among 2199 patients, 24.1% to 90.5% and 71.2% to 92.7% were considered adherent when using fixed interval and prescription-based interval medication possession ratios [MPRi and MPRp] respectively, depending on how concurrent medications were handled. Adherence was inversely associated with death, with the strongest association for MPRp measures. This association was significant only when considering adherence to any anti-hypertensive [aOR 0.70, 95% CI 0.51, 0.97], or when the mean of the class-specific MPRp’s [adjusted OR 0.71, 95% CI 0.53, 0.95] was used. No significant association existed when the highest or lowest class-specific MPRp was used as the adherence estimate.

Conclusion

The range of adherence estimates varies widely depending on the operational definition used. Given less variation in adherence rates and their stronger association against mortality, we recommend using prescription-based MPR’s to define medication adherence.

[Future Perspective of Pharmacoepidemiology in the "Big Data Era" and the Growth of Information Sources]

The arrival of new drug into the market requires many years of previous research along with the need of continuous evaluation throughout the lifetime of the drug. This warrants pharmacoepidemiological research which may be defined as the study of the use and the effects of drugs in large populations. Nowadays this type of research seems more feasible thanks to the massive expansion of the information sources and data (e.g: clinical patient registries, electronic medical records). However there is a risk of information overload, fragmented evidence and given the enthusiasm aroused by the "Big Data", it must be emphasized that its nature is mainly observational, and therefore subject to bias and confusion. The application of epidemiological methods in this scenario seems essential for any analysis. In short, the management and use of these data sources to generate useful information expansion is the next challenge for the application of research methods in modern pharmacoepidemiology.

Constructing a Real-Time Prescription Drug Monitoring System

Objectives

The objective of this investigation was to demonstrate the possibility of the construction of a real-time prescription drug monitoring system (PDMOS) using data from the nationwide Drug Utilization Review (DUR) system in Korea.

Methods

The DUR system collects information on drug prescriptions issued by healthcare practitioners and on drugs dispensed by pharmacies. PDMOS was constructed using this data. The screen of PDMOS is designed to exhibit the number of drug prescriptions, the number of prescriptions dispensed by pharmacies, and the dispensed prescription drug costs on a daily and weekly basis. Data was sourced from the DUR system between June 1, 2016 and July 18, 2016. The TOGA solution developed by the EYEQMC Co. Ltd. of Seoul, Korea was used to produce the screen shots.

Results

Prescription numbers by medical facilities were more numerous than the number of prescriptions dispensed by pharmacies, as expected. The number of prescriptions per day was between 2 to 3 million. The prescriptions issued by primary care clinics were most numerous, at 75% of the total number of prescriptions. Daily prescription drug costs were found to be approximately US $50 million. The prescription drug costs were highest on Mondays and were reduced towards the end of the week. Prescriptions and dispensed prescriptions numbered approximately 1,200 and 1,000 million, respectively.

Conclusions

The construction of a real-time PDMOS has been successful to provide daily and weekly information. There was a lag time of only one day at the national level in terms of information extraction, and scarcely any time was required to load the data. Therefore, this study highlights the potential of constructing a PDMOS to monitor the estimate the number of prescriptions and the resulting expenditures from prescriptions.

Cost-Sharing Rates Increase During Deep Recession: Preliminary Data From Greece

Background: Measures taken over the past four years in Greece to reduce pharmaceutical expenditure have led to significant price reductions for medicines, but have also changed patient cost-sharing rates for prescription drugs. This study attempts to capture the resulting increase in patients’ out-of-pocket (OOP) expenses for prescription drugs during the 2011-2014 period.

Methods: The authors conducted a retrospective review of financial data derived from 39 883 prescriptions, dispensed at three randomly chosen pharmacies located in Lamia, central Greece.

Results: The study recorded an average contribution rate per prescription as follows: 11.28% for 2011 (95% CI: 10.76-11.80), 14.10% for 2012, 19.97% for 2013, and 29.08% for 2014. Correspondingly, the mean patient charge per prescription for 2011 was €6.58 (95% CI: 6.22-6.94), €8.28 for 2012, €8.35 for 2013, and €10.87 for 2014. During the 2011-2014 period, mean percentage rate of patient contribution increased by 157.75%, while average patient charge per prescription in current prices increased by 65.22%. The use of a newly introduced internal reference price (IRP) system increased the level of prescription charge at a rate of 2.41% for 2012 (100% surcharge on patients), 26.24% for 2013 (49.95% on patients and 50.04% on the appropriate health insurance funds), and 47.72% for 2014 (85.06% on patients and 14.94% on funds).

Conclusion: Increased cost-sharing rates for prescription drugs can reduce public pharmaceutical expenditure, but international experience shows that rising OOP expenses can compromise patients’ ability to pay, particularly when it comes to chronic diseases and vulnerable populations. Various suggestions could be effective in refining the cost-sharing approach by giving greater consideration to chronic patients, and to the poor and elderly.

Views and attitudes of oral contraceptive users towards their availability without a prescription in the Republic of Ireland

Background:

Previous studies show that provision of oral contraceptive pill (OCs) without a prescription is safe, feasible and effective and that users are interested in obtaining contraception in this way, especially if a pharmacist screening is involved. A recent national survey conducted in the Republic of Ireland has highlighted that unintended pregnancy resulting from the failure of OCs could be linked to poor compliance due to costs and difficulty of access.

Objective:

To evaluate views and attitudes of OC users towards the availability of OCs without a prescription in the Republic of Ireland.

Methods:

A cross sectional survey was conducted using an opportunistic sample of OC users aged 18 to 50 years. Sixty community pharmacists were recruited nationwide. Data were collected using self-completed questionnaires. The questionnaires comprised information on: demographic data, need of the service, views on the availability of OCs without prescription, advantages and concerns around the service, role of pharmacists and cost implications for private and public patients.

Results:

A total of 488 eligible OC users completed the survey. The majority of the respondents (71.7%;n = 350/488) reported to have missed a pill for reasons connected to the OCs prescription status and 55.5% (n = 268/488) of the respondents reported to have felt distressed on at least one occasion because they could not renew their OC prescription. A total of 87.9% (n = 429/488) of the respondents said they were in favour of OCs being available without prescription and 92% (n = 448/488) said they were likely to obtain OCs without prescription if available. Convenience and ease of access were indicated as the main advantages of availing of OCs without prescription, while safety was the biggest concern reported. Over 88% (n = 430/488) of the respondents indicated that pharmacists would be able to safely supply OCs without prescription. Private patients expected to save an average of 27.3% on their OC if obtained without prescription.

Conclusions:

OC users in the Republic of Ireland are in favour of OCs being available without prescription and are willing to obtain it this way, providing that pharmacists supply them according to protocols that facilitate the safety and the efficacy of the supply. An easier and more convenient access to OCs could also reduce the likelihood of missed pills and bring considerable savings to users.

Primary care physicians' use of FDA-approved prescription drug labels

BACKGROUND

In 2006, the US Food and Drug Administration reorganized the approved label format and content for prescription drugs -also known as the prescribing information (PI). This research examines primary care physicians' use of the new PI and how it may influence their perceptions about prescription drugs.

METHODS

A total of 500 physicians responded to an Internet survey that displayed an interactive PI for a fictitious combination pain relief/heart attack-reducing drug. The physicians answered questions about perceived risk, perceived benefit, and intention to prescribe that focused on either the treatment indication or the prevention indication.

RESULTS

Physicians viewed PI sections in order, most often viewing sections relevant to safe use, such as Warnings and Precautions and Dosage and Administration. When asked to think about the drug's efficacy, many viewed the Clinical Studies section. Viewing certain PI sections was associated with greater perceived risk and lower perceived benefits and intention to prescribe.

CONCLUSIONS

These results suggest that the information in the PI could affect physician decision making and do not support further reorganization of the PI.

Digesting the doughnut hole

Despite its success, Medicare Part D has been widely criticized for the gap in coverage, the so-called "doughnut hole". We compare the use of prescription drugs among beneficiaries subject to the coverage gap with usage among beneficiaries who are not exposed to it. We find that the coverage gap does, indeed, disrupt the use of prescription drugs among seniors with diabetes. But the declines in usage are modest and concentrated among higher cost, brand-name medications. Demand for high cost medications such as antipsychotics, antiasthmatics, and drugs of the central nervous system decline by 8-18% in the coverage gap, while use of lower cost medications with high generic penetration such as beta blockers, ACE inhibitors and antidepressants decline by 3-5% after reaching the gap. More importantly, lower adherence to medications is not associated with increases in medical service use.

Professional practices and perception towards rational use of medicines according to WHO methodology in United Arab Emirates

Inappropriate prescribing reduces the quality of medical care and leads to a waste of resources. No study has been reported concerning rational drug use in United Arab Emirates, UAE, recently.

OBJECTIVES

assessing patterns of use and defining problems regarding the rational drug use.Setting baseline situational analysis study for practices in the health care system relevant to drug use.

METHOD

A descriptive pilot study, consisting of pharmacists, physicians and patients (100 of each of category) from four private hospitals, (12) medical clinics, (80) community pharmacies in addition to 150 prescriptions. A questionnaire of three sections was designed to include WHO indicators regarding patients, facility and prescribing patterns that are relevant to rational drug use was carried out in four emirates of the UAE in the period December 2008-Febreuary 2009.

RESULTS

Consultation and dispensing times were 10 (SD=2.75) min and 68 (SD=9.7) seconds, respectively. Average no. of drugs per prescription was (2.9 + 0.97), % of prescriptions using generic name (7.35%), % of antibiotic containing prescriptions (31.1%), % of injection containing prescriptions (2.9%), adherence to Standard Treatment Protocols (46%), adherence to the essential drug list (64%), patient's knowledge of correct dosage (55%), adequately labeled drugs (45%), patient's information (65%).

CONCLUSIONS

Several areas of deficiency in rational drug use had been defined in the private sector through UAE that can be remedied through adopting several strategies such as adherence to national standard treatment guidelines and essential drug list based on treatments of choice, interaction between health care system and providing drugs information to consumers.